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Name F�i l�A:�
Unit
Block
Lot
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Date of Mark-out �
Date of Burial
� � ! Time / , ('�i� �c ' - ` i
Name of f
Authorize
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_ ___.
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Paid by CEMETERY Receipt No. . .. 369, , , , , , , , , Dated . .4�? �84 . . . . . . . . . . . . . . . . . . . . NO.
. 300 00 -2-
List Pna S . . . . . . : . . . . . . . . . . . Maximum No. Eucial Spaces . . . . . . . . . . . . . . . . . ` i
Net Paid s , _ 3 00 : 00 . . . . . . . . Monument permitted , , FI d t . . . . . . . . . . . . . . . . 1 � 1.J 1
Lots 23 & 24, B1ock 38, Unit 1 Additional Elizabeth T, or Gregory B. Pa1mE
941 Louisiana Ave.
(Data �bo�e t�bL lfne for City Recoed only) Sebastian, Florida 32958
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.� State of Florida, Departmer Health and Rehabilitative Services, Vital 8 tics ,✓�
APPLICATION FOR BURIAL — TRANSIT PERMIT �=� j��
A. (Type or Print)
1. Name of First Middle Last DATE Month Day Year
Deceased Elizabeth 7'. Palmer• �F Uy/` �/yl
DEATH "r
2. Place of Death
County
lnciian Kivei
3. Name of Medical
Certifier
i�uul• t�1eT•i:1lEint
City, Town or Location
4. Name of Funeral Home/
Direct Disposer
Sti•unk Funeral Homes
5. Check
Appro-
priate
Box
�
7
e.
C.
a �
Sebastiaii
Medical Examiner
Name of (If neither, give street address)
Hosp. or
Inst. 11:i3U S. Indian River Dr. #�0
Address Phone Number
77�� Bay Stt'eet.tSuil;e L
Physician S�bastian, Fl.�i�icia 3295i3 (�U7 ) �8�-0�3 i�3
Address Fla. Lic. No./Reg. No. Phone Number (Area Code)
16'L3 Nort;}� Centi�al Avenu
, P.A. Sebastian, Fl `329�8 12`L$ (407)562-`L�`L7
The medical certification has been completed and signed. A completed certificate of death accompanies
this application.
b� j� �� was contacted on ��-+ i� � iQ � within 72
hours after death. He/she verified that this death was from natural causes, that there was no accident
nor other external cause of death, and that Noc,r• i�ierc}►a«t will complete
and sign the medical certification of cause of death.
c ❑
medical certification.
Place of Sebastian Cemetery In state cemetery/
Final Disposition: crematory - na
Funeral Director/ � � ignatur
{3irec,^t�6i�ryeseK- �.,�' �
was contacted on . He/she verified that
, Medical Examiner, will complete and sign the
Indian River
F.E. No./Reg. No.
BURIAL — TRANSIT PERMIT
Removal
from state n Donation
Date Signed
Permission is hereby granted to dispose of this body.
Permit No. 1'L`Lt3-91-0-� 12
❑ A five day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted as undue hardship
would result from filing within the normal time limit. If the certificate cannot be filed within this extended time limit, a"Funeral Director/Direct
Disposer ReporY' will be filed with the Local Registrar of the County in which death occurred.
❑ No extension of time for filin he death certificate requ sted.
Registrar or Date ��� � Date Certificate
Subregistrar Signature _ � Issued: �- � Due:
AUTHORIZATION for CREMATION, DISSECTION or BURIAL—AT—SEA
Signature , Medical Examiner Date
or
Medical Examiner, , gave authorization by telephone to
Funeral Director/Direct Disposer. Date
The Medical Examiner's approval must be obtained before disposal by any of the above methods. A waiting period of 48 hours after
death is required for all cremations.
�� CEMETERY OR CREMATORY
�
Methods of Disposition: ���_,5 �/ � � � �J.
Place of Dispositio
�BURIAL ❑ STORAGE Date of Disposition � �
❑ CREMATION ❑ OTHER (Specify)
Signature of Sexton )
or Person-in-Charge )
This permit must be endorsed by the Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton)
and returned within 10 days to the local HRS County Public Health Unit in the County where disposition occurred.
HRS Form 326. Feb 89 IReolaces Oct 87 edition which mav be usedl